New Membership Application
Personal Information Section
Name
*
First Name
Middle Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
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Additional Information Section
Date of Birth
*
/
Month
/
Day
Year
Date Picker Icon
Driver License’s / ID Card #
*
Issuing State (Driver License’s / ID Card)
*
Not Applicable
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Vehicle Year / Make / Model
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Personal History Section
Employers Name
*
Time at current Job (years)
*
Have you ever been convicted of any felony in the last 10 years?
*
No
Yes
Have you ever been convicted of any misdemeanor in the last 3 years?
*
No
Yes
Is there any pending changes of any felony or misdemeanor?
*
No
Yes
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Radio Communication Section
Amateur Call Sign
Amateur License Class
None
Technician
General
Extra
GMRS Call Sign
Do you have a Base Station?
CB
GMRS
MURS
Amateur HF
Amateur VHF
Amateur UHF
Amateur Digital
Plan Old Telephone (Wire Line)
Do you have a Mobile Radio?
CB
GMRS
MURS
Amateur HF
Amateur VHF
Amateur UHF
Amateur Digital
Public Safety (not a scanner)
Do you have a Hand-held Radio?
CB
GMRS
MURS
Amateur HF
Amateur VHF
Amateur UHF
Amateur Digital
Public Safety (not a scanner)
Cellular Telephone (Mobile Phone)
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Current Training Section (non-required to join)
REACT International
101 Emergency Communications
102 Introduction to Land Search and Rescue
103B Protecting Personal and Sensitive Information
103C Using the Zello Voice Training and Operations Nets
104 Monitoring
105 Introduction to Net Operations
109A Messages – The Radiogram
109B Messages – ICS 213 General Message
110 Deployment Awareness
111 Basics of Drills and Exercises
113 Disaster Basics
114 Alerting
115 The Emergency Operations Plan
116 Introduction to Net Control
117 Spot Reporting
120 Traffic System Operator Basic Familiarization
National Incident Management System
ICS-100 (Online)
ICS-200 (Online)
ICS-700 (Online)
ICS-800 (Online)
ICS-300 (Classroom only)
ICS-400 (Classroom only)
Community Emergency Response Team
Basic CERT
Advance CERT
Auxiliary Communications
AUXCOMM
Nation Weather Service
Basic Skywarn
Advanced Skywarn
Emergnecy Medical Training
Basic CPR / AED / First aid by Red Cross or American Heart Association
Healthcare Providers CPR / AED / First Aid by American Heart Association
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Medical History Section
Do you have any allergies (including food)?
*
No
Yes
If yes, list allergies.
Do you have any chronic illness or physical handicap?
*
No
Yes
If yes, please list illnesses or handicaps.
Are you willing to donate blood?
*
Yes
No
Blood type (if known)
unknown
O positive: 35%
O negative: 13%
A positive: 30%
A negative: 8%
B positive: 8%
B negative: 2%
AB positive: 2%
AB negative: 1%
Doctor’sName
Doctor’s Phone Number
Please enter a valid phone number.
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Emergnecy Contacts Section
List your Emergency Contacts
Emergnecy Contact (1) (Required) Name
*
First Name
Last Name
Emergnecy Contact (1) (Required) Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergnecy Contact (1) (Required) Phone Number
*
Please enter a valid phone number.
Emergnecy Contact (2) (Required) Name
*
First Name
Last Name
Emergnecy Contact (2) (Required) Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergnecy Contact (2) (Required) Phone Number
*
Please enter a valid phone number.
Emergnecy Contact (3) (Optional) Name
First Name
Last Name
Emergnecy Contact (3) (Optional) Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergnecy Contact (3) (Optional) Phone Number
Please enter a valid phone number.
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Other Information Section
Do you belong to any other club or organization?
*
No
Yes
If Yes, list club club or oranization.
Have you ever served in the military?
*
No
Yes
If yes, list Branch, Rank, and duties.
Have you ever previously been a member of a REACT Team?
No
Yes
Other
If Yes, list prior team # and reason for leaving.
Were you recommended by a member of this REACT team?
No
Yes
If Yes, list who recommended you.
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Declaration Section
I do hereby agree to abide by all rules and regulations set forth in the monitoring guide and the Consitution and Bylaws of Harris / Galvestion Countu REACT Team #6272, Inc. I understand that upon my voluntary resignation of dismissal for any cuase for this organization I will be obligated to return to the organization, within seven (7) days, all and any items which are the property of the ogranization, including but not limited to those which bear any officially recognized REACT International or Harris / Galvestion County REACT Team identification.
*
If you agree type, I agree
I do hereby agree to all provisions of the application, and attest that all information contained herein is true and correct.
*
If you agree type, I agree
Type your legal name to sign the application.
*
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